Preventive or not?

maine4me

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Would someone please help me out....again? I pulled this note for an audit based on the billed code which was 99212. However, during my review I notice that the nurse indicated the reason for the visit was a yearly PE. There is no HPI or ROS that I see and it looks like components of a PE are here, I am just not sure it is comprehensive enough. What do you think?

Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
272.0 Hypercholesterolemia

401.9 HYPERTENSION NOS

278.02 Overweight

Additional Orders:
Prescriptions
Renewed -
Rosuvastatin Calcium (Crestor 10 Mg Tablet) 10 MG TAB
10 MG PO DAILY, Qty 30 TAB, 11 Refills
Rosuvastatin Calcium (Crestor 20 Mg Tablet) 20 MG TABLET
20 MG PO DAILY, Qty 30 TAB, 11 Refills
Amlodipine Besylate (Amlodipine 5 Mg Tablet) 5 MG TAB
5 MG PO DAILY, Qty 30 TAB, 11 Refills
Propranolol Hcl (Propranolol 40 Mg Tablet) 40 MG TAB
40 MG PO THREE TIMES A DAY, Qty 90 TAB, 11 Refills
Triamterene 37.5 Mg/Hctz 25 Mg (Maxzide 25 Mg Tablet) 1 TAB TAB
1 TAB PO DAILY, Qty 30 TAB, 11 Refills
Lisinopril (Zestril 20 Mg Tablet) 20 MG TAB
20 MG PO TWICE A DAY, Qty 60 TAB, 11 Refills

Additional Plan Details:
Pt interviewed, pt examined, labs reviewed, note imrpoved creatinine, refills printed at desk, pt to stay on same RX, pt to RTO PRN for one year for Dr and FU and labs (CBC, CMP, UA, Lipids, one week before for med monitor, elev chol)
Education resources provided: No
Referred for colonoscopy: No
Tobacco counseling given: Other - none
Alcohol counseling given: None
Substance use counseling given: None
Weight - BMI High: Patient counseled

HPI
HPI
Nursing Chief Complaint: yearly check up, refused weight

Physician: []
Vitals:
Height 64 in / 162.56 cm
Pulse 80
Blood Pressure 150/88 Sitting, Left Arm
Personal Medical History
Personal medical history: Hx of: High Blood Pressure

Social History
Social history:
Marital Status: Single

Problem List
-----

Past Medical/Surgical History
Chronic Problems:
Hypercholesterolemia
HYPERTENSION NOS

EXAM
*****
*****
Pt in no distress, repepated BP = 135/85

Constitutional
General Appearance: NAD

Eyes
Eye: Bilateral: Normal inspection

Chest
Chest appearance: Normal

Respiratory
Respiratory effort: Normal
Auscultation: Bilateral: Normal

Cardiovascular
Rhythm: Regular
Heart sounds: Normal: S1, S2

Neurologic
Neuro Exam: Grossly Intact, Nonfocal

Psychiatric
Mental status: Grossly normal
 

Evelyn Kim

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Local Chapter Officer
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San Antonio, TX
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I do not see any HPI or ROS either. I don't think it even meets the annual physicial exam either because I don't see any assesment or treatment plan for the listed problems.

Hope this helps.
 
Messages
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Location
Milwaukee WI
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Preventive Visit

This note is odd ... the A/P is at the top of the note, then the history and finallly the exam.

Anyway ... you have a preventive visit.

Per the CPT guidelines:
The "comprehensive" nature of the Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synomymous with the "comprehensive" examination required in Evaluation and Management codes 99201-99350. (emphasis is in CPT book guidelines)


Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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